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Update on new recommendations
By Dr. Joel Doughten
What % of new
recommendations recommended
by the USPSTF is out of date by
the time it is published?
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A. 5%
B. 9%
C. 12%
D. 15%
Answer
• B. 9%
What is the average length of
time that a recommendation
made by the USPSTF in in effect
before it is revised?
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A. 5.4 years
B. 7 years
C. 7.5 years
D. 10 years
Answer
• A. 5.4 years
Should you vaccinate a 25 yo
smoker with Pneumovac?
• A. Yes
• B. No
• C. Consider
Current Change by the USPSTF
• Asthma and cigarette smoking have been
added as indications for pneumococcal
polysaccharide vaccination #7. Also, text
has been added to clarify vaccine use in
Alaska Natives and American Indians.
Pneumococcal polysaccharide
vaccine (Pneumovax)
• ACIP recommendations—smokers 19 to 64 yr of age
• Relative risk for pneumococcal invasive disease higher in
smokers
• smoking, diabetes, and asthma have comparable risk
• among smokers, risk 1 per 10,000;
• problems—when to administer and frequency
• vaccine wears off with time
• hyporesponsiveness occurs after second dose
• if smokers revaccinated every 5 to 10 yr, low
responsiveness expected by age 65 yr
Case: patient—man 61 yr of
age; smoker; last tetanus
vaccine
15 yr ago; never given Tdap; he
is adopting a daughter
from Guatemala in 1 month.
What vacines should you give
him?
recommended
vaccines
• Tdap based on high risk (smoker) and need for tetanus
booster
• pneumococcal polysaccharide based on age and high risk
(smoker)
• inactivated influenza vaccine
• herpes zoster based on age
• hepatitis A, based on daughter adopting from Guatemala
• varicella not indicated (born before 1980)
• hepatitis B risk not identified
• Meningococcal conjugate not indicated
A girl 12 yr of age presents with
sports
injury. She has no chronic
illnesses and is in good health.
She had all her childhood
vaccines
by age 5 yr. What vaccines do
you recommend?
recommended vaccines
• tetanus and diphtheria toxoids and acellular
pertussis (Tdap) for adolescents
• influenza (universal annual administration 6 mo
through 18 yr of age)
• varicella (catch-up if second dose not received)
• quadrivalent meningococcal conjugate vaccine (all
children 11-12 yr of age)
• human papillomavirus (HPV all girls 11-12 yr of
age)
• hepatitis A (catch-up for ages 11-12 yr [depending
on state regulations] and universally for ages 1-2
yr)
Identify the correct statement about the
Gardasil human papillomavirus (HPV)
vaccine.
(A) Licensed for males and females 9 to
26 yr of age
(B) Protects against HPV strains 6, 11,
16, and 18
(C) Protects against HPV infection even
if patient has been infected with HPV in
the past
(D) Licensed for pregnant women
Answer
• (B) Protects against HPV strains 6, 11, 16,
and 18
Which of the following is(are) true about
meningococcal vaccines?
1. Meningococcal conjugate vaccine is
recommended for routine use in adolescents
2. Meningococcal polysaccharide vaccine is
recommended for adults <50 yr of age
3. Meningococcal vaccines are recommended for
freshmen college students, molecular biologists, and
travelers
4. Meningococcal vaccines can be administered to
those with a history of Guillain-Barré syndrome
(A) 1, 2, 3, 4 (B) 1, 2, 3 (C) 1, 3 (D) 2, 3, 4
Answer
• 1. Meningococcal conjugate vaccine is
recommended for routine use in adolescents
• 3. Meningococcal vaccines are
recommended for freshmen college
students, molecular biologists, and travelers
• (C) 1, 3
Identify the correct statement
about the herpes zoster vaccine.
(A) Recommended for both
adolescents and adults
(B) Prevents herpes zoster and
postherpetic neuralgia
(C) Indicated for pregnant
women
(D) Stored at room temperature
Answer
• (B) Prevents herpes zoster and postherpetic
neuralgia
Hepatitis A vaccine is recommended for
which of the following?
1. 30-yr-old man backpacking in South
America
2. 28-yr-old woman adopting a child
from Guatemala
3. 25-yr old man addicted to drugs
4. 35-yr-old homosexual man
(A) 1 (B) 1, 2 (C) 1, 2, 3 (D) 1, 2, 3, 4
Answer
• Hepatitis A vaccine is recommended for
which of the following?
• 1. 30-yr-old man backpacking in South
America
• 2. 28-yr-old woman adopting a child from
Guatemala
• 3. 25-yr old man addicted to drugs
• 4. 35-yr-old homosexual man
• (D) 1, 2, 3, 4
Whom of the following should
receive the influenza vaccine?
1. 6-yr-old schoolboy
2. Mother of 2-yr-old twins
3. Nurse who works in the
emergency department
4. 60-yr-old diabetic
(A) 1 (B) 1, 2 (C) 1, 2, 3 (D) 1, 2,
3, 4
Answer
• 1. 6-yr-old schoolboy
• 2. Mother of 2-yr-old twins
• 3. Nurse who works in the emergency
department
• 4. 60-yr-old diabetic
• (D) 1, 2, 3, 4
The risk for pneumococcal
invasive disease is higher for:
(A) Smokers, but not for
diabetics or asthmatics (C)
Smokers and asthmatics, but not
for diabetics
(B) Diabetics, but not for
smokers or asthmatics (D)
Smokers, diabetics, and
asthmatics
Answer
• (D) Smokers, diabetics, and asthmatics
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The USPSTF Updated:
December 2009
Summary of Recommendations
The USPSTF recommends biennial screening mammography for women aged 50 to 74 years.
Grade: B recommendation.
The decision to start regular, biennial screening mammography before the age of 50 years should be an
individual one and take patient context into account, including the patient's values regarding specific benefits
and harms.
Grade: C recommendation.
"So, what does this mean if you are a woman in your 40s? You should talk to your doctor and make an informed
decision about whether mammography is right for you based on your family history, general health, and personal
values."
Diana Petitti, MD, MPH
Vice Chair, U.S. Preventive Services Task Force
November 19, 2009
The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of
screening mammography in women 75 years or older.
Grade: I Statement.
The USPSTF recommends against teaching breast self-examination (BSE).
Grade: D recommendation.
The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of
clinical breast examination (CBE) beyond screening mammography in women 40 years or older.
Grade: I Statement.
The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of
either digital mammography or magnetic resonance imaging (MRI) instead of film mammography as screening
modalities for breast cancer.
Grade: I Statement.
On December 4, 2009, the USPSTF unanimously voted to update the language of their recommendation regarding
women under 50 years of age to clarify their original and continued intent.
Studies suggest that clinicians
would need to perform
mammography on _______
women 40 to 49 yr of age to avert
a
single death from breast cancer.
(A) 25 (B) 250 (C) 2500 (D)
25,000
Answer
• (C) 2500
Benefits of screening mammography
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Women 40-49 yr of age
trial in United Kingdom (2006)— 11-yr follow-up
16% decrease in breast cancer mortality among screened vs nonscreened
women at 10 to 11 yr
Canadian trial (1980s)—showed no effect
Takehome message—modest benefit observable only with long follow-up;
number needed to screen (NNS)—2500 women 40 to 49 yr of age to avert 1
death (25,000 annual mammograms)
most studies done in United Kingdom
US case-control studies (Elmore 2005 and Norman 2007)—no difference in
mortality
case-control studies usually overestimate benefit
Women 50 yr of age: 30% reduction in mortality in screened women
benefit seen in 5 yr
tighter confidence intervals and benefit persists over long period
270 women every 2 yr for 20 yr to avert 1 death (ie, 2700 mammograms)
Women 70 yr of age and older little data is available on mortality in
randomized controlled trials (RCTs)
population-based data—better detection in screened group, but no significant
difference in mortality
Question: How often
should women 50 to 69 yr
of age undergo
mammography? A) every
year; B) every 1 to 2 yr;
C) every 2 yr; D) every 3
yr
Answer
• C) every 2 yr
RCTs comparing annual vs
biennial screening
• — no difference in breast cancer mortality
• population-based data (Breast Cancer Surveillance Consortium)—
from United States
• looked for increase in late-stage disease with biennial vs annual
screening
• Proportion of advanced-stage disease decreases with age (tumors not
as aggressive in older women)
• in women over 50 yr of age the proportion of advanced-stage cancer
was the same with annual and biennial screening
• for younger women (40-49 yr of age), 21% of cancers late-stage
disease in annual group vs 28% in biennial
• 7% difference may warrant annual
• Screening
• Canadian study—annual vs biennial screening in women 50 to 69 yr
of age the 10-yr survival was the same
Recommendations to reduce the frequency of
mammography from once per year to once
every 2 yr for women 50 to 69
yr of age are based on:
(A) Data showing no increase in breast cancer
mortality with biennial vs annual screening
(B) Data showing no increase in late-stage
breast cancer with biennial vs annual
screening
(C) Data showing no difference in 10-year
breast cancer survival rates with biennial vs
annual screening
(D) All the above
Answer
• (D) All the above
Patient characteristics
and breast cancer
• Hormone therapy (HT): taking estrogen and
progestin for >5 yr increases rate of cancer and
advanced disease
• explanations—estrogen and progestin promote
tumor growth, increase breast density, and mask
tumors
• Only 15% of postmenopausal women now using
hormone therapy
• decreased use associated with lower incidence of
breast cancer (particularly estrogen receptor–
positive disease [13% per year])
Use of estrogen and progestin
therapy for 5 yr increases the
risk for breast cancer and for latestage disease due to the
hormones’ potential to:
(A) Promote tumor growth
(B) Increase breast density
(C) Decrease breast density
(D) A and B
Answer
• (A) Promote tumor growth
• (B) Increase breast density
• (D) A and B Answer
Breast
density
• It is reported with some mammograms (eg,
• fatty, scattered fibroglandular densities,
heterogeneously dense, very dense)
• most women in middle of range
• effect of breast density on detection—higher
density both increases risk for breast cancer
and makes it more difficult to detect
• unpublished data—higher density correlates
with more advanced disease
• consider annual screening, or use of digital
mammography
Family history and
Obesity
• Family history (first-degree relative)
• no effect on ability to detect cancer
• more abnormalities noted and biopsies performed, possibly
due to clinician bias
• survival study—no difference with positive family history
• screening—not necessary to screen more often than others
• Obesity: increases risk for breast cancer and advanced
disease
• attributed to extra estrogen in adipose tissue, rather than to
difficulties with detection
Choose the correct statement about patients
with a first-degree relative who has had breast
cancer.
(A) It is more difficult to detect breast cancer
in these patients
(B) They are no more likely than other
patients to be referred for further investigation
of abnormalities found on
mammography
(C) Studies show no difference in survival
rates for these patients
(D) They should undergo twice-yearly
mammography
Answer
• (C) Studies show no difference in survival
rates for these patients
Minimizing false
positives and negatives
• limit hormone use
• avoid biopsy by using comparison films
• Encourage weight loss (increased breast
tissue leads to more false positives)
• refer to high-volume facilities (have better
specificity)
• counsel patients that breast augmentation
decreases sensitivity of mammography
To prevent false-positives and
false-negatives in breast cancer
screening, the patient should do
which of the following?
(A) Avoid hormone therapy
(B) Obtain comparison films
(C) Obtain screening at a highvolume facility(
D) All the above
Answer
• (D) All the above
Sensitivity of digital mammography
is higher than that of film
mammography for women 40 to 49
yr of age who are both
_______ and who have _______.
(A) Premenopausal; dense breasts
(B) Premenopausal; fatty breasts
(C) Postmenopausal; dense breasts
(D) Postmenopausal; fatty breasts
Answer
• (A) Premenopausal; dense breasts
Cost-effectiveness
• compare benefit to harm
• women 50 to 69 yr of age
• most cost-effective at $21,400/yr of life
saved
• smoking cessation much more effective way
to reduce clinical burden of disease and
costs
The sensitivity of digital
mammography is higher than
film mammography for which
groups of women?
A) premenopausal
B) 40 to 49 yr of age;
C) with dense breasts;
D) all of these
Answer
• D) all of these (must fall into all 3
categories
• women >65 yr of age with fatty
• breast tissue—film mammography gives
better contrast
A women at high risk for breast cancer should
undergo
which screening tests?
A) mammography;
B) clinical breast examination
(CBE)
C) ultrasonography
D) mammography and
ultrasonography
E) mammography and magnetic resonance
imaging (MRI)
F) mammography, CBE and MRI
Answer
• Answer: no correct answer
• depends on definition of high risk
• mammography and MRI—standard of care
for carriers of breast cancer mutation
• MRI twice as sensitive as mammography,
but less than half as specific
• tests usually alternated every 6 mo for
mutation carriers
For women at average risk for
breast cancer, screening
should include mammography
and:
(A) Clinical breast
examination (C) A and B
(B) Breast self-examination
(D) Neither A nor B
Answer
• (D) Neither A nor B
D) none of these
• CBE—sensitivity 54%
• does not decrease mortality when combined with
mammography
• increases false positives
• Effectiveness of BSE
• 3 large RCTs in China, Russia, and United
Kingdom—BSE vs usual care; after long follow-up
• no difference in mortality
• to teach BSE the potential consequences are an
increase in benign biopsies and physician visits
Possible
recommendations
• inform women of potential benefits and
consequences of screening
• in women 50 to 69 yr of age,
mammography every 2 yr
• consider CBE in women who refuse
• in women over 70 yr of age, stop
mammography
• consider CBE in patients who request it
A study mandated by the US Food and Drug
Administration found that:
(A) Women with silicone breast implants had
fewer complications than those with saline
implants
(B) Women with silicone implants had less
severe complications than those with saline
(C) Silicone and saline implants were
associated with similar types and severity of
complications
(D) Silicone implants were unsafe in certain
age groups of women
Answer
• (C) Silicone and saline implants were
associated with similar types and severity of
complications
HIV in United States:
in 2008
• 56,000 people newly infected with HIV
• 1.3 million people in United States living
with HIV;
• 25% of HIV-infected individuals unaware
of infection
• Twice as many infections transmitted before
diagnosis (>50% of new HIV infections
transmitted by those with undiagnosed
disease)
Centers for Disease Control and
Prevention (CDC) HIV screening
recommendations (2006):
• test all persons 13 to 64 yr of age in all health
care settings
• especially where other tests routinely done
• patients notified of HIV testing on general consent
form (opt-out screening)
• test patients with high-risk behaviors (eg, multiple
sex partners, intravenous drug users1 time/yr
• no testing interval for individuals without known
risk factors
• but test all patients 1 time
Rationale for Routine
Screening for HIV Infection
• Previous CDC and U.S. Preventive Services Task Force
guidelines for HIV testing recommended routine
counseling and testing for persons at high risk for HIV and
for those in acute-care settings in which HIV prevalence
was >1% (9,10,24). These guidelines proved difficult to
implement because 1) the cost of HIV screening often is
not reimbursed, 2) providers in busy health-care settings
often lack the time necessary to conduct risk assessments
and might perceive counseling requirements as a barrier to
testing, and 3) explicit information regarding HIV
prevalence typically is not available to guide selection of
specific settings for screening (25--29).
Screening for HIV
Infection
• In all health-care settings, screening for HIV infection should be
performed routinely for all patients aged 13--64 years. Health-care
providers should initiate screening unless prevalence of undiagnosed
HIV infection in their patients has been documented to be <0.1%. In
the absence of existing data for HIV prevalence, health-care providers
should initiate voluntary HIV screening until they establish that the
diagnostic yield is <1 per 1,000 patients screened, at which point such
screening is no longer warranted.
• All patients initiating treatment for TB should be screened routinely
for HIV infection (108).
• All patients seeking treatment for STDs, including all patients
attending STD clinics, should be screened routinely for HIV during
each visit for a new complaint, regardless of whether the patient is
known or suspected to have specific behavior risks for HIV infection.
Repeat Screening
• Health-care providers should subsequently test all persons likely to be
at high risk for HIV at least annually. Persons likely to be at high risk
include injection-drug users and their sex partners, persons who
exchange sex for money or drugs, sex partners of HIV-infected
persons, and MSM or heterosexual persons who themselves or whose
sex partners have had more than one sex partner since their most recent
HIV test.
• Health-care providers should encourage patients and their prospective
sex partners to be tested before initiating a new sexual relationship.
• Repeat screening of persons not likely to be at high risk for HIV
should be performed on the basis of clinical judgment.
• Unless recent HIV test results are immediately available, any person
whose blood or body fluid is the source of an occupational exposure
for a health-care provider should be informed of the incident and tested
for HIV infection at the time the exposure occurs.
Consent and Pretest
Information
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Screening should be voluntary and undertaken only with the patient's
knowledge and understanding that HIV testing is planned.
Patients should be informed orally or in writing that HIV testing will be
performed unless they decline (opt-out screening). Oral or written information
should include an explanation of HIV infection and the meanings of positive
and negative test results, and the patient should be offered an opportunity to
ask questions and to decline testing. With such notification, consent for HIV
screening should be incorporated into the patient's general informed consent
for medical care on the same basis as are other screening or diagnostic tests; a
separate consent form for HIV testing is not recommended.
Easily understood informational materials should be made available in the
languages of the commonly encountered populations within the service area.
The competence of interpreters and bilingual staff to provide language
assistance to patients with limited English proficiency must be ensured.
If a patient declines an HIV test, this decision should be documented in the
medical record.
Communicating test
results
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The central goal of HIV screening in health-care settings is to maximize the number of
persons who are aware of their HIV infection and receive care and prevention services.
Definitive mechanisms should be established to inform patients of their test results.
HIV-negative test results may be conveyed without direct personal contact between the
patient and the health-care provider. Persons known to be at high risk for HIV infection
also should be advised of the need for periodic retesting and should be offered
prevention counseling or referred for prevention counseling. HIV-positive test results
should be communicated confidentially through personal contact by a clinician, nurse,
mid-level practitioner, counselor, or other skilled staff. Because of the risk of stigma and
discrimination, family or friends should not be used as interpreters to disclose HIVpositive test results to patients with limited English proficiency. Active efforts are
essential to ensure that HIV-infected patients receive their positive test results and
linkage to clinical care, counseling, support, and prevention services. If the necessary
expertise is not available in the health-care venue in which screening is performed,
arrangements should be made to obtain necessary services from another clinical
provider, local health department, or community-based organization. Health-care
providers should be aware that the Privacy Rule under the Health Insurance Portability
and Accountability Act of 1996 (HIPAA) prohibits use or disclosure of a patient's health
information, including HIV status, without the patient's permission.
Partner Counseling
and Referral
• When HIV infection is diagnosed, health-care providers
should strongly encourage patients to disclose their HIV
status to their spouses, current sex partners, and previous
sex partners and recommend that these partners be tested
for HIV infection. Health departments can assist patients
by notifying, counseling, and providing HIV testing for
partners without disclosing the patient's identity (114).
Providers should inform patients who receive a new
diagnosis of HIV infection that they might be contacted by
health department staff for a voluntary interview to discuss
notification of their partners.
HIV in the United
States
geography—mainly in metropolitan areas
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• rates in rural areas increasing;
• infection rates highest in Miami, followed by Baltimore
and Washington DC
• Ethnicity and sex—although blacks 13% of US population,
in 2006, blacks comprised 50% of new US AIDS cases and
90% of
• new AIDS cases in Maryland
• HIV predominantly in black men, but rates of HIVpositive Hispanic men and black women increasing
• data from Africa indicate that infection in women will
equal and perhaps exceed those in men over time
HIV transmission patterns
• heterosexual contact—fastest increasing
route of transmission
• more efficient in women than men
(transmission to receptive sexual partner
more efficient than to insertive partner)
• accounts for 80% of new cases in women
• receptive anal intercourse—most common
route of transmission in men
Diagnosis of AIDS often missed
• claims data from 8 US health maintenance organizations reviewed;
• Dentified >7500 cases with potentially AIDS-defining diagnoses (eg,
Pneumocystis pneumonia [PCP], cryptococcal meningitis, lymphoma,
invasive cervical cancer) with no diagnosis of HIV
• 4% tested for HIV during period from 5 mo before to 2 mo after
AIDS-defining diagnosis made
• conclusion— primary care physicians not testing for HIV in inpatient
and outpatient care
• several major organizations of internists and
obstetricians/gynecologists recommend universal HIV screening
• American Academy of Family Physicians (AAFP) has not yet taken
position
• goal to make HIV testing as routine as cholesterol screening
• CDC recommends that specific written consent no longer be required
• Federal government denies Ryan White HIV funding to states
requiring specific written consent
Criteria for screening
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HIV meets all criteria
1) serious health problem
2) can be diagnosed before symptoms
Develop
3) diagnosis inexpensive and noninvasive
4) major health gains when treated before
symptoms develop
• 5) screening cost-effective (dollars saved by
avoiding acute care exceed testing costs)
Reasons for reluctance to screen
• my patients do not want HIV test
• patients assume HIV testing done when
blood drawn for other tests
• routine testing eliminates stigma associated
with testing and decreases need to screen
for risk factors (determining risk factors still
important for prevention)
• there is little HIV in my practice—
Testing
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recommended in areas where prevalence >0.1% (most areas in United States)
patients routinely screened for low-prevalence diagnoses, eg, invasive cervical cancer
Discussing HIV testing takes too much time—pretest counseling not required
inform patients about opt-out consent on general consent form (opting-out indication for
further discussion)
Retesting at provider's discretion (previous recommendation to retest after 3 mo, but not
necessary if no risky behaviors)
Negative results may be given by phone or letter
we do too many screening tests—simple test (eg, serum, saliva, or fingerstick blood
test)
can order when blood drawn for common laboratory tests
in-office tests cost $8 to $16
what do I do if it is positive?
discuss with patient; have supportive other present, if possible
explain health status and benefits of immediate treatment
Notify partner anonymously or in office
educate about preventing transmission (eg, condoms, safer sex)
recommend limited disclosure of status (potential sex partners and supportive others)
offer social work and mental health support
obtain laboratory tests and schedule 2- to 3-wk follow-up visit
Initial work-up of HIV
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CD4 (absolute number and percent)
viral load
baseline genotype
complete blood count (CBC; anemia common in HIV
patients)
metabolic profile (look for hepatitis and kidney disease)
fasting lipid profile (for cholesterol baseline, because
ARVs affect cholesterol)
test for other sexually transmitted diseases (STDs)
Screen for hepatitis A, B, and C and immunize against
hepatitis A and B if patient not immune)
skin test for tuberculosis
Annual Papanicolaou test
Interpretation of results
• CD4 count—determines stage of disease and whether OIP and/or
ARVs needed
• CD4 count <200/mL—AIDS defined
• OIP and ARVs needed
• CD4 count 200/mL to 350/mL—ARVs needed
• OIP not needed
• CD4 count 350/mL to 500/mL—consider ARVs
• CD4 >500/mL— may defer ARVs
• possible indicators to start ARV when CD4 count >350/mL—any stage
of pregnancy (to prevent transmission to fetus)
• HIV-associated nephropathy (refer patient
• with any renal impairment to nephrologist for biopsy)
• VL >100,000 indicates rapid HIV progression
• CD4 count falling >100 points/yr
• active chronic hepatitis B or C
• 50 yr of age, due to age-accelerated effect (however, no evidence of
benefits in treating older HIV patients at earlier stages)
Interpretation of results
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Percent CD4—indicates proportion of WBCs that are CD4 cells
Less variable than absolute CD4 count
CD4 percent <14 defines AIDS
VL—maps disease over time
useful in monitoring therapy
monitor VL progression
goal is undetectable VL by ultrasensitive tests
women have lower VLs than men at same stage of disease (eg, women at risk for rapid progression
with VL 50,000
baseline HIV genotype—checks for resistance before choosing treatment
10% of patients initially infected with resistant virus transmitted from patient taking ARVs (in HIV
patient not on ARVs, virus mutates back to wild type)
In some cases, multiple HIV strains present due to virus mutation
in viral subpopulations, genotype may not show resistance, as one strain dominant (usually wild type;
resistance will likely occur when treatment implemented)
Hepatitis panel—if hepatitis B virus (HBV) surface antigen (HbsAg) present (ie, active HBV
infection), check HBV DNA, which indicates stage of HBV infection and quantity present
if hepatitis C virus (HCV) antibody present, check HCV RNA
10% of patients with HCV infections recover
VL indicates active HCV infection or past infection
VL helps physician choose medications and timing of initiation
coinfection (HIV with HBV or HCV) speeds progression of both diseases
Prophylaxis of opportunistic
infections
• start if indicated
• no resistance, even if patient partially compliant
• CD4 <200/μL—co-trimoxazole (Bactrim) single or double
strength once daily for PCP prophylaxis; if allergic to
Bactrim, and mycobacterium avium intracellulare complex
(MAC) prophylaxis
• treat MAC with azithromycin 1200 mg once weekly or 600
mg twice weekly (if patient has nausea)
• Do not give prophylaxis if patient already has MAC (risk
for resistance)
• if signs of MAC infection present (eg, unexplained fever or
anemia), take culture for MAC
• if culture negative, start prophylaxis
Starting ARVs
• do not start until patient ready
• Increased risk for resistance with missed doses
• MAC prophylaxis one way for patient to practice
taking medications daily
• Increases probability of compliance with treatment
• Address barriers (eg, depression, substance abuse)
• 85% to 90% compliance required for ARV
effectiveness
• Resources: San Francisco Warm Line (800-9333413)—
• http://www.nccc.ucsf.edu/; open 24 hr; questions
answered by phone or email
For which of the following types of
patients should antiretroviral medications
(ARVs) be prescribed?
(A) Pregnant woman, CD4 count
400/mL
(B) Man who has sex with men, CD4
count 360/mL, viral load (VL) >100,000
(C) Black woman, CD4 count >500,
active hepatitis C virus (HCV) infection
(D) All the above
Answer
• (D) All the above
Which of the following
gives information about
resistance to ARVs?
(A) VL
(B) CD4 count
(C) Genotype
(D) CD4 percentage
Answer
• (C) Genotype
All the following statements are true, except:
(A) During prophylaxis for opportunistic
infections, resistance can develop if doses are
missed
(B) Prophylaxis for Pneumocystis pneumonia
should be started when the CD4 count is
<200/mL
(C) It is acceptable to substitute dapsone for
co-trimoxazole if the patient is allergic to cotrimoxazole
(D) Start prophylaxis for Mycobacterium
avium-intracellulare complex when the CD4
count is <50/mL
Answer
• (A) During prophylaxis for opportunistic
infections, resistance can develop if doses
are missed
All the following statements about Chlamydia
trachomatis are true, except:
(A) C trachomatis can infect the throat and
cause symptoms
(B) Cultures may be used to test for
Chlamydia in throat and rectum
(C) The recommended treatment for pregnant
women is levofloxacin (1-g oral dose)
(D) Azithromycin is the standard treatment for
chlamydial infections
Answer
• (C) The recommended treatment for
pregnant women is levofloxacin (1-g oral
dose)
Choose the true statement about gonorrhea.
(A) The Gram stain is recommended for
screening in women
(B) Ceftriaxone is recommended treatment in
all adults and adolescents
(C) Quinolones are recommended for
treatment of men who have sex with men and
for recent immigrants
(D) Culture on Thayer-Marten plates is not
recommended by the Centers for Disease
Control and Prevention (CDC)
Answer
• (B) Ceftriaxone is recommended treatment
in all adults and adolescents
A CD4 count <200 cells/μL
signifies a(an) _______ stage of
HIV infection.
(A) Early
(B) Intermediate
(C) Late
(D) Very late
Answer
• (C) Late
In an HIV-positive patient not on
highly active antiretroviral
therapy (HAART), a CD4 count
more than
_______ old is not reliable.
(A) 4 wk
(B) 2 mo
(C) 3 mo
(D) 4 mo
Answer
• (C) 3 mo
In the HAART era, which of the
following organisms is the most
common cause of pneumonia in
the HIV
patient?
(A) Streptococcus pneumoniae
(B) Pneumocystis jerovici
(C) Haemophilus influenzae
(D) Klebsiella pneumoniae
Answer
• (A) Streptococcus pneumoniae
HIV itself is a
significant independent
risk factor for
cerebrovascular disease.
(A) True (B) False
Answer
• A) True
Which of the following statements about
HAART and psychiatric illness are true?
1. Depression and demoralization extremely
common in HIV patients and significant
factors in compliance
2. Common early side effects of efavirenz
include nightmares and irritability
3. Psychosis not an uncommon side effect of
efavirenz
4. Most psychiatric side effects resolve within
4 wk of discontinuation of medication
(A) 1,3 (B) 2,4 (C) 1,2,3 (D) 1,2,3,4
Answer
• 1. Depression and demoralization extremely
common in HIV patients and significant
factors in compliance
• 2. Common early side effects of efavirenz
include nightmares and irritability
• 3. Psychosis not an uncommon side effect
of efavirenz
• 4. Most psychiatric side effects resolve
within 4 wk of discontinuation of
medication
• (D) 1,2,3,4
Adolescents’
perception of sex
• oral sex precedes or substitutes for
intercourse
• black and Hispanic boys almost twice as
likely as whites to engage in anal
intercourse
• anal and oral sex perceived as abstinence by
some
Study of adult sexual
practices
• 12,571 men and women 15 to 44 yr of age
surveyed (79% response rate)
• results—one-third of men and women have
had anal sex
• Threequarters of men and women have had
oral sex
• condom use during last oral or anal sex
uncommon
Effect of values on
behavior
• condoms worn only for vaginal sex to
prevent pregnancy and HIV
• oral sex not considered adultery
• prostitutes require condoms for vaginal sex,
but not oral sex
• friends require condoms for vaginal sex, but
not oral sex
• female can engage in oral and anal sex and
still be considered virgin
Questions to ask when patients
say, “I always use a condom”
•
•
•
•
for all sexual activity?
for vaginal and/or anal, but not oral sex?
for vaginal sex only?
importance of sexual history—how and
what questions asked and responses
determine
• nature of screening for STDs